March 1, 2018 Daniel Clavio Dear Mr. Clavio, For... · 2018-04-25 · subsidiaries, joint ventures,...

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March 1, 2018

Daniel Clavio

New Mexico Human Services Department

ARK Plaza: 2025 S Pacheco Street, Santa Fe, NM 87504

Dear Mr. Clavio,

The All Pueblo Council of Governors respectfully submits our response to the

Request for Information Regarding the Establishment of an Indian Managed Care Entity

(IMCE) for New Mexico Native American Medicaid Members issued by the State of New

Mexico (NM) Human Services Department (HSD). We are writing to formally express our

interest in collaborating with HSD as an IMCE to provide the full spectrum of Medicaid

benefits to Medicaid eligible Native Americans in compliance with all requirements of the

Centennial Care 2.0 Contract and applicable state and federal regulations.

The All Pueblo Council of Governors has the intent to fully cooperate, satisfy and

act in good faith and with due diligence to comply with requirements of this RFI. Subject to

and limited by the inherent challenges resultant from the short time period of time from the

issuance and release of the RFI by HSD and the required filing date of the response, we

have made our best efforts to describe, within the RFI response, our approach, experience

and capacity to establish an IMCE within the timeline as outlined by HSD.

Sincerely,

____________________________________

Chairman E. Paul Torres

All Pueblo Council of Governors

All Pueblo Council of Governors

Response to the State of New Mexico

Request for Information Regarding the Establishment of an

Indian Managed Care Entity for New Mexico Native American

Medicaid Members

Issue Date: January 25, 2018 Response Due Date: March 1, 2018

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018

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1. Submit a description of your organization’s form of business (e.g., individual, sole proprietor, corporation, nonprofit corporation, partnership, limited-liability company) and detail the names, addresses, and telephone numbers of its officers and directors and any partners, if applicable, as well as the person the State should contact regarding your organization’s information. Provide your organization’s federal and State taxpayer identification numbers.

DESCRIPTION OF ORGANIZATION

The All Pueblo Council of Governors (APCG) has granted authority for the development of a Bureau of Indian Affairs Section 17 Tribal Corporation of the 19 Pueblos to apply as an IMCE in New Mexico (hereinafter referred to as “19 Pueblos Entity”). Such Corporation shall be established pursuant to applicable law and shall involve all 19 Pueblos. Geographic Coverage Area. APCG proposes an IMCE geographical coverage area to include the following contiguous counties: Bernalillo, Cibola, Las Alamos, McKinley, Rio Arriba, Sandoval, Santa Fe and Taos, and Valencia Counties. Contact Person. For questions regarding this proposed structure or other content within this RFI response, please contact: Erik Lujan Chairman of All Pueblo Council of Governors Health Committee Home: [email protected] Phone: 505-280-2811 2. Provide copies of all your organization’s articles of incorporation, bylaws, partnership agreements, or similar business entity documents, including any legal entity having an ownership interest of five percent (5%) or more. APCG has granted authority for the development of a tribally owned entity, 19 Pueblos Entity, to apply as an IMCE in New Mexico. Because the 19 Pueblos Entity is not yet formed, we are not submitting any articles of incorporation, bylaws, partnership agreements or similar business entity documents at this time. Should an RFP or request to negotiate result from this RFI, APCG will submit all applicable documentation at that time. 3. Describe how your organization will comply with net worth, solvency, reinsurance, and surplus requirements and maintain a fidelity bond that meets the amount specified in the Centennial Care contract and for the time specified under the New Mexico Insurance Code. APCG, through the development of the 19 Pueblos Entity, is confident in its ability to meet all financial management requirements as outlined in the New Mexico Insurance Code, New Mexico statutes, the Centennial Care Contract and applicable federal rules and regulations. Additionally, APCG is already in discussions with a national Medicaid Managed Care Organization to form a strategic partnership that will support the 19 Pueblos Entity to serve as an IMCE, providing administrative function supports and financial management services. This could include elements that impact the 19 Pueblos Entity’s financial status with considerations of

mailto:[email protected]


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obtaining reinsurance through our strategic partner. Other considerations in discussion with our strategic partner include a minority share being purchased with contributions to capital which would strengthen the corporate net worth or financial strength to sustain solvency and the 19 Pueblos Entity’s ability to meet other financial requirements and needs. APCG also reserves the right and intent to fully explore any and all such potential strategic relationships in addition to or in lieu of our identified strategic partner for the same purpose. APCG also welcomes discussions with any non-Pueblo tribe that may desire to be a participating member or strategic partner, including the possibility of ownership, governance and/or financial responsibility, as a part of our ambition to serve all Native Americans in New Mexico. Representatives of APCG have already begun discussions around this concept and will continue to explore and potentially present additional partners as part of a response to any subsequent RFP or request to negotiate that may result from this RFI. 4. Describe your organization’s relationship and provide any relevant documentation regarding your organization’s relationship to parent, affiliated, and/or related business entities, including but not limited to subsidiaries, joint ventures, or sister companies. Include a copy of the management agreement with any parent organization, if you are owned by a corporation or are an affiliate or subsidiary. APCG has authorized the development of a Bureau of Indian Affairs Section 17 Tribal Corporation of the 19 Pueblos to apply as an IMCE in New Mexico. As noted above, APCG has identified a strategic partner that will support the 19 Pueblos Entity to serve as an IMCE, providing administrative function supports and financial management services. Also noted above, APCG may engage additional strategic partners including possibility of ownership, governance and/or financial responsibility. Should an RFP or request to negotiate result from this RFI, APCG will be prepared to submit applicable documentation at that time. 5. Provide (i) a copy of your organization’s NM license (as issued by the NM Office of Superintendent of Insurance (OSI)), or evidence that an application for a NM license is in process, that allows the assumption of risk for prepaid capitated contracts under New Mexico State law and (ii) a copy of any report filed with the OSI during the last twelve (12) months. APCG nor its intended 19 Pueblos Entity has made application to the New Mexico OSI for licensure as a risk bearing prepaid capitated contractor. The licensure process is not only very burdensome and lengthy, but it requires the submission of information such as Board of Directors, staff and other required personnel that have not been selected nor is there sufficient time in which to complete background checks and the necessary due diligence that is mandated. Further, the licensure application requires certain representations and financial guarantees which APCG have not fully finalized, completed and/or pursued on behalf of this interest and it is premature for any such information and/or the application to be submitted. Generally, the NM OSI provides up to thirty (30) days in the event a deficiency is determined in an application and if not cured within that time frame the application is withdrawn by act of OSI. Therefore, APCG, even though it has the intent to fully cooperate, satisfy and act in good faith and with due diligence to comply with this requirement of the RFI, finds that it is not feasible, given the short


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period of time from the issuance and release of the RFI by HSD and the required filing date of the response, to make a complete, accurate and truthful representation and application for licensure as an HMO. APCG fully believes that given an appropriate opportunity and amount of time that a complete, accurate and truthful application for licensure can be made and that the receipt of a license can be obtained under more favorable and fair circumstances. Upon development of the 19 Pueblos Entity, we will apply for and obtain an HMO License to serve as an IMCE in New Mexico. We will keep HSD apprised of our progress with submission and subsequent approval of our licensure application with OSI and do not foresee any problems in attaining a NM license within the timeframes required to serve as an IMCE in 2019. APCG has not filed any reports with the OSI during the last twelve (12) months. 6. Include a statement of whether, in the last ten (10) years, your organization, a predecessor company, your parent organization, affiliates, and/or subsidiaries has filed (or had filed against it) any bankruptcy or insolvency proceeding, whether voluntary or involuntary, or undergone the appointment of a receiver, trustee, or assignee for the benefit of creditors. If so, provide an explanation detailing relevant facts, including the date on which your company emerged from bankruptcy or expects to emerge. If still in bankruptcy, provide a summary of and anticipated timeframe for approval of a plan of reorganization. Neither APCG, nor any predecessor company, parent organization, affiliate, and/or subsidiary, has filed (or had filed against it) any bankruptcy or insolvency proceeding, whether voluntary or involuntary, or undergone the appointment of a receiver, trustee, or assignee for the benefit of creditors in the last ten (10) years. 7. Provide copies of the your organization’s most recent audited financial statements for each line of business operated, showing a separation between commercial and public accounts and among various contracts and various public fund sources for which your organization is responsible. APCG is a non-profit organization that does not receive income. APCG therefore does not have any audited financial statements to submit as part of this RFI response. As noted above, APCG is already in discussions with a national managed care entity to form a strategic partnership that will support the 19 Pueblos Entity to serve as an IMCE, providing administrative function supports and financial management services and reserves the right to add additional strategic partners. Upon finalization of such strategic partnerships and as part of any subsequent RFP or request to negotiate resultant from this RFI, the 19 Pueblos Entity will submit applicable audited financial statements for those partners. 8. Provide an organizational chart or diagram of the organizational structure your organization will employ to fulfill the requirements of the Centennial Care 2.0 contract. The organizational chart or diagram should present information clearly and concisely and include, at a minimum, health plan functions including but not limited to key staff and roles in areas including (contract management, IT / data systems (includes claims processing, encounter data submission and reporting), finance, quality / disease management, care coordination, actuarial support, etc.), lines of reporting, and the physical location of staff and functional/program areas. The organizational chart should show the corporate structure and lines of responsibility and authority in the


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administration of your organization’s business as a health plan. Include a narrative description to supplement the chart(s). APCG’ organizational philosophy is locally driven accountability and decision making. Our model requires that we develop and maintain a highly-qualified, New Mexico-based staff who share our health plan’s passion for providing exceptional service to the members, providers, and communities we serve. The New Mexico-based Chief Executive Officer (CEO) of the 19 Pueblos Entity will have authority over all IMCE operations for the HSD program and report to the 19 Pueblos Entity’s Board of Directors. All management staff who interface with members and providers, such as Member and Provider Representatives, as well as Marketing, Care Coordination, Utilization Management, Quality Improvement, Network Contracting, Provider Relations/ Engagement, Grievance and Appeals, and Compliance personnel, and employees of our strategic partners, will be located in our New Mexico headquarters. Additionally, we will employ and locate staff such as Care Coordination and Provider Relations/Engagement across the state, in the communities we serve, as field-based or co-located staff within provider offices. Our proposed staffing model was established to comply with all functions, requirements, roles, and duties required by the Centennial Care 2.0 Contract. See graphic below for a diagram of our proposed organizational structure including key staff and functional areas.


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19 Pueblos EntityBoard of Directors

Chief Finance Officer

Chief Medical Director

Compliance

Officer

VP, Integrated Health Services

Chief Operating

Officer

Contract Manager

Implementation

Manager & Support Services

Director, Human Resources

Director,

DSNP

19 Pueblos EntityCEO

Director, Member

& Provider Services

Director, Pharmacy

Director, Network

Development & Contracting

Director, Care Coordination

Key Staff Positions as required by Centennial

Care 2.0 Contract

Manager, Vendor

Oversight

VP, Quality Improvement

DSNP Medical

Director

Director, LTSS

Claims Administrator

Manager, Marketing & Communications

Manager, Enrollment

Director,

Utilization Management

Director, External Relations

Director, Provider Relations/

Engagement

Manager,

Grievance and Appeals

Behavioral

Health Medical Director

Native American

Liaison

Member Advocate/

Ombudsman

Chief

Information Officer

* Note: All staff who interact directly with members or providers will be located in

New Mexico. Strategic Partner support staff may be located outside of New Mexico

Information Technology

Support

Finance

Department Support

Human

Resources Support

Claims/Encounters Support

Compliance and

SIU/Fraud & Abuse Support

Credentialing and

Provider Data Management

Centene Management Company

Strategic Partner Staff

IMCE Staffing Model


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9. Provide the names, titles, job descriptions and resumes of the proposed personnel that will fulfill the following roles for your MCO organization in New Mexico. Resumes are to be attached to your response. a. CEO of Centennial Care 2.0 b. CFO of Centennial Care 2.0 c. CIO of Centennial Care 2.0 d. Implementation Manager e. Medical Directors f. Long-Term Services and Support Manager g. Contract Manager It is the intent of APCG, through its new 19 Pueblos Entity, to attempt to identify and locate key staff and personnel from within the current framework and organizations of the 19 participating Pueblo health care systems and networks. In the event that not all of the positions can be filled from within, it is the intent of the 19 Pueblos Entity to recruit, identify and hire the most qualified and capable personnel, including candidates of Native American descent with ties to New Mexico, utilizing practices in compliance with all applicable fair employment standards. APCG’s national managed care entity strategic partnership currently being developed will also serve to augment our recruitment and staffing capabilities, ensuring that we draw personnel from the broadest, best qualified pool of candidates. Please see Attachment.9_Job Descriptions for job descriptions for each of the positions noted in the question above. The 19 Pueblos Entity will submit names, titles, and resumes of proposed personnel as part of any subsequent RFP or request to negotiate resultant from this RFI.. 10. Provide a Centennial Care 2.0-specific work plan that captures (i) key activities and timeframes, and (ii) projected resource requirements from your organization for implementing requirements specified in the Centennial Care 2.0 contract. The work plan should cover activities through “go-live”. The date of “go-live” should be no later than July 1, 2019. APCG, through its 19 Pueblos Entity confirms we will be ready to serve all eligible members by the July. 1, 2019, go-live date. Our detailed implementation and operational action plan includes the planning, implementation and evaluation of elements necessary to facilitate a successful implementation. The 19 Pueblos Entity will design and manage a well-organized work plan, which will guide our progress toward fulfilling all contract deliverables. Our work plan, designed using Microsoft Project software, will group all tasks related to relevant functional areas, including, but not limited to, Provider Network, Human Resources, Facilities, Member Services, Provider Services, Claims and Configuration, and Integrated Health Services, such as our readiness review and specific reporting requirements. Each delineated task included on the work plan will correspond with a Start Date, End Date, Current Status, and Accountable Team field to ensure continuous tracking and progression of each task. Tasks associated within the overall key milestones of our work plan are noted in the table below.

The 19 Pueblos Entity - Implementation Project Plan Milestones

Project Milestone Planned Completion

Actual Completion Status

Identify MSO and Conduct Pre-Delegation Audits 4/30/2018 In Process


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HSD Notice of Award 7/2/2018 Implementation Kick Off Meeting with Business Development 7/10/2018

Contract Executed with HSD 7/15/2018 Finalize Contract with MSO 8/1/2018 IT Business Requirements Development 10/31/2018 Staffing Model Approved 10/31/2018 Finalize Operating Model 10/31/2018 Member Acquisition Strategy Complete 10/31/2018 Network Strategy Complete 10/31/2018 Begin Readiness Process with HSD 10/31/2018 Complete MCO Licensure in NM 10/31/2018 Enrollment Summary Complete 11/16/2018 Key Personnel Hired and Trained 11/16/2018 Develop Partnership Strategy with local delivery systems/stakeholders 11/16/2018 Desk Readiness Review Submission to HSD 12/15/2018 Provider Network Complete 1/30/2019 IT Agile Development Cycles Complete 1/30/2019 IT Production UAT Complete 1/30/2019 Network Adequacy Submission to HSD 2/15/2019 Internal Readiness 3/1/2019 Integration and End to End Testing w/ State (eligibility, claims, encounters, etc.) Complete 4/30/2019 Pay classes and Benefits Configuration Complete 3/15/2019 Claims Operations Team and Systems Operational 3/30/2019 Integrated Care Team and Systems Operational 3/30/2019 Service Operations Team and Systems Operational 3/30/2019 Membership and Billing Team and Systems Operational 3/30/2019 State System Readiness Demos/ Operational Readiness 4/1/2019 Providers Loaded and Displaying in FAP 4/30/2019 Open Enrollment begins 5/1/2019 Member Auto Assignment begins 6/1/2019 Welcome Calls Begin 7/1/2019 Implementation Go-Live 7/1/2019 First Claims Check Run 7/15/2019 Implementation to Operations Transition Complete 11/1/2019 Lessons Learned Complete 11/30/2019 State Milestones Start Finish Status Readiness Review Guidance 7/2/2018 7/30/2018 On Schedule Enrollment Period Defined 7/2/2018 7/30/2018 On Schedule Auto Assignment Algorithm Determined 7/2/2018 7/30/2018 On Schedule IT Integration and End to End Testing w/ IMCE (eligibility, claims, encounters, etc.)

3/1/2019 4/30/2019 On Schedule

Provide Production 834 Eligibility File for Go Live 6/15/2019 6/20/2019 On Schedule Business Implementation Milestones Start Finish Progress Develop Implementation SharePoint Site 7/2/2018 7/10/2018 On Schedule Develop State Q&A Grid, Issues/Risks Logs 7/9/2018 12/30/2018 On Schedule


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Develop Executive Reviews and EISC 7/9/2018 8/10/2018 On Schedule Develop IT Deliverable Grid 7/9/2018 8/10/2018 On Schedule Identify and Clarify Integrated Lead Roles 7/20/2018 7/30/2018 On Schedule Finalize Operating Model 7/20/2018 8/6/2018 On Schedule Participate HSD Meetings (daily, weekly, monthly) 7/20/2018 On-Going On Schedule Facilitate weekly Integrated Lead and Cross-Functional Workgroup Calls 7/20/2018 On-Going On Schedule

Finalize Implementation work plan 8/30/2018 8/30/2018 On Schedule Facilitate External Readiness Review 11/1/2018 11/15/2018 On Schedule Prepare Go-Live Metrics & Schedule Meetings 5/1/2019 6/30/2019 On Schedule Schedule Transition to Operations Meeting 10/1/2019 10/30/2019 On Schedule Develop Playbook/Resource Guide for Operations 11/1/2019 2/28/2020 On Schedule Schedule Lessons Learned Meeting 11/30/2019 11/30/2019 On Schedule HR/Facilities Milestones Start Finish Progress Site Surveys Complete 6/15/2018 7/15/2018 On Schedule Temp Space Identified / Lease Signed 8/15/2018 9/15/2018 On Schedule Staffing Model Finalized 8/30/2018 9/15/2018 On Schedule Org Chart and Key Staff Submitted to State 9/4/2018 9/15/2018 On Schedule Hiring for key positions finalized 11/1/2018 3/30/2019 On Schedule New employee training begins 3/15/2019 6/1/2019 On Schedule Permanent Space Move In 6/1/2019 6/30/2019 On Schedule Member Milestones Start Finish Progress Enrollment Marketing Plan Submitted to State 9/4/2018 10/1/2018 On Schedule New member materials packet (member handbook, ID card, provider directory, etc.) sent to State for approval 9/4/2018 10/1/2018 On Schedule

Open Enrollment/Direct Member Marketing Begins 5/1/2019 6/30/2019 On Schedule Member Call Center Live for Open Enrollment 5/1/2019 5/30/2019 On Schedule Open Enrollment Ends, Direct Marketing Materials collected from provider offices and replaced with educational materials

6/30/2019 6/30/2019 On Schedule

Member Welcome Calls and New Member Mailings begin 7/1/2019 Ongoing On Schedule Provider Milestones Start Finish Progress Provider Contracting Materials sent to State 9/4/2018 10/1/2018 On Schedule Preliminary Provider Manual submitted to State for approval 9/4/2018 10/1/2018 On Schedule

Credentialing criteria due to State 9/4/2018 10/1/2018 On Schedule Provider Contracting Mailing sent to Providers 10/1/2018 3/31/2019 On Schedule Subcontracts (BH, DM, Pharmacy, Vision, other member services, etc.) due to State 10/1/2018 11/2/2018 On Schedule

Final Provider Manual Submitted to State for approval 11/15/2018 10/1/2018 On Schedule Providers Loaded and Displaying in FAP 2/1/2019 3/30/2019 On Schedule Provider Network Adequacy/Provider Directory due to State 4/15/2019 4/30/2019 On Schedule

Provider Trainings and Orientations Complete and Provider Audit Program Finalized 6/30/2019 7/30/2019 On Schedule

Systems/Claims/Eligibility & Enrollment Milestones Start Finish Progress State/Health Plan Systems Integration Testing 3/1/2019 4/30/2019 On Schedule Load and Test initial 834 File 3/1/2019 4/30/2019 On Schedule


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Receive Production 834 Eligibility File for Go Live 5/1/2019 6/30/2019 On Schedule Complete Medicaid Enrollment 6/30/2019 6/30/2019 On Schedule First Claims Check-Run 7/15/2019 7/15/2019 On Schedule First Encounters Run Configured 7/30/2019 7/30/2019 On Schedule Compliance / Regulatory/SIU Start Finish Progress Assure Disaster Recovery/Business Continuity Plan meets State requirements 7/2/2018 9/1/2018 On Schedule

Customization of Compliance and Privacy Policies 7/2/2018 9/1/2018 On Schedule Customize Policy & Procedures for State Contract Requirements 7/2/2018 9/1/2018 On Schedule

Develop Contract Grid 7/2/2018 8/30/2018 On Schedule Draft Compliance Charter 7/2/2018 9/1/2018 On Schedule Draft Compliance work plan 7/2/2018 9/1/2018 On Schedule Establish Program Integrity/Fraud, Waste and Abuse Programs 7/2/2018 9/1/2018 On Schedule

Identify state document approval requirements and manage submission 7/2/2018 9/1/2018 On Schedule

Participate in State Committees (Administrative Simplification, Behavioral Health Integration, Quality Assurance Performance) as needed

7/2/2018 Ongoing On Schedule

Customize/Develop Reports (Internal & State) 9/1/2018 12/30/2018 On Schedule Manage policy and procedure process; If State determines P&P inefficient or unnecessary burden, work with State 9/4/2018 12/15/2018 On Schedule

Submit compliance plan to State (if needed) 9/4/2018 10/1/2018 On Schedule Implement subcontractor oversight process 10/1/2018 Ongoing On Schedule Submit any subcontracts for review and approval 10/1/2018 11/2/2018 On Schedule Hire Compliance Staff 11/1/2018 3/30/2019 On Schedule Compliance Training for all Staff - in person training for all team members 4/1/2019 6/30/2019 On Schedule

Establish and convene Compliance Committee 4/1/2019 7/30/2019 On Schedule Training - for all Key Positions for Compliance team at HP 4/1/2019 6/30/2019 On Schedule

Begin delivery of reports with appropriate data verification (42 CFR 438.606) 7/1/2019 Ongoing On Schedule

Quality Management & Quality Improvement Start Finish Progress Update Policies and Procedures and QM deliverables for State Requirements 7/2/2018 9/1/2018 On Schedule

Develop QI program, work plan and evaluation 7/2/2018 9/1/2018 On Schedule Develop QI committee charters & recruit providers for required committees 7/2/2018 9/1/2018 On Schedule

Hire and Train Staff 4/1/2019 6/30/2019 On Schedule Attend State Quality Management Committee 7/2/2018 Ongoing On Schedule Identify and capture all data and reporting requirements 7/2/2018 9/1/2018 On Schedule NCQA accreditation Process initiated and Director Assigned prior to Go live 4/1/2019 Ongoing On Schedule

Establish and convene Quality Improvement Committees (QIC) 3/1/2019 Ongoing On Schedule

Establish and convene QI Committees (Credentialing) 3/1/2019 Ongoing On Schedule Establish and convene QI Committees (UM) 10/1/2019 Ongoing On Schedule


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Information Management / Information Systems Start Finish Progress Kickoff IT Portion of Project & assure compliance with NM Technology requirements 7/2/2018 9/1/2018 On Schedule

Develop IT Deliverable Grid 7/2/2018 9/1/2018 On Schedule Update Policies and Procedures and Compliance/360 for State requirements 7/2/2018 9/1/2018 On Schedule

Develop Core Application Requirements 7/2/2018 10/1/2018 On Schedule Develop IT Operating Model 7/2/2018 9/1/2018 On Schedule Develop IT Infrastructure 9/1/2018 4/30/2019 On Schedule Enroll as an EDI Trading Partner with the State 9/1/2018 4/30/2019 On Schedule Portico IT (Vendor Set up, File Load) 9/1/2018 4/30/2019 On Schedule Setup Interfaces with State Systems 10/15/2018 1/30/2019 On Schedule Setup and Test Provider FTP site 10/15/2018 1/30/2019 On Schedule Configure, deploy, test: Websites, Member & Provider Portals, and Member Mobile Applications 10/15/2018 1/30/2019 On Schedule

Set-up standard HIPAA files and code sets 10/15/2018 1/30/2019 On Schedule Onboard and Certify New Trading partners 10/15/2018 1/30/2019 On Schedule Configure, deploy, test: Security Infrastructure 10/15/2018 1/30/2019 On Schedule Configure, deploy, test: Provider Data Management System 10/15/2018 1/30/2019 On Schedule

Configure, deploy, test: Medical Management System (Tricare) 10/15/2018 1/30/2019 On Schedule

Configure, deploy, test: Claims Processing 10/15/2018 1/30/2019 On Schedule Configure, deploy, test: Encounter Processing 10/15/2018 1/30/2019 On Schedule Configure, deploy, test: Call Center Telephony and Service Systems 10/15/2018 1/30/2019 On Schedule

Configure, deploy, test: Infrastructure (Network and Field Office hardware, software, LAN, and services) 10/15/2018 1/30/2019 On Schedule

Contingency and Continuity Plans 10/15/2018 1/30/2019 On Schedule Configure, deploy, test: Member Database for Eligibility and Enrollment 10/15/2018 1/30/2019 On Schedule

Configure, deploy, test: Centelligence EDW, and configure MicroStrategy Reports 10/15/2018 1/30/2019 On Schedule

Integration Testing for Member, Provider, Authorizations, Claim, Encounters, Portals 3/1/2019 4/30/2019 On Schedule

Software Integration Testing 3/1/2019 4/30/2019 On Schedule Recruit, Hire and Train Health Plan IT Staff 4/1/2019 6/30/2019 On Schedule Configuration for IT Systems Complete 4/1/2019 4/1/2019 On Schedule Integrated Physical and Behavioral Health Care Start Finish Progress Integrated Health Services Kick-off 7/9/2018 7/13/2018 On Schedule Customize medical management P&Ps to meet NM requirements 7/9/2018 9/1/2018 On Schedule

Finalize Staffing Model 7/9/2018 9/1/2018 On Schedule New Business SharePoint 7/9/2018 7/13/2018 On Schedule Define CM/UM Programs and Requirements 7/9/2018 9/1/2018 On Schedule Define reporting needs - State specific 9/1/2018 12/30/2018 On Schedule Develop/Customize Forms and Assessments (HRS, HRA, NOP, etc.) 9/1/2018 12/30/2018 On Schedule


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Review State Benefits - Determine Plan Benefits 9/1/2018 12/30/2018 On Schedule Obtain Prior Authorization listing 9/1/2018 12/30/2018 On Schedule CM Process Training 9/4/2018 12/15/2018 On Schedule Configure Forms, Assessments and Letters in TruCare 1/1/2019 3/30/2019 On Schedule Define and configure Continuity of Care protocols 1/1/2019 3/30/2019 On Schedule Develop ARQ based on PA listing 1/1/2019 3/30/2019 On Schedule Service Types configured in TruCare 1/1/2019 3/30/2019 On Schedule Authorization guidelines created 1/1/2019 3/30/2019 On Schedule Business Rules configured in TruCare 1/1/2019 3/30/2019 On Schedule Other content configured in TruCare (Dropdown values, queues, etc.) 1/1/2019 3/30/2019 On Schedule

Load Structured notes 1/1/2019 3/30/2019 On Schedule Member Eligibility Crosswalk/ Mapping UMV or EDI 1/1/2019 3/30/2019 On Schedule Provider Eligibility Crosswalk/ Mapping 1/1/2019 3/30/2019 On Schedule Authorization Load Validation - UAT 1/1/2019 3/30/2019 On Schedule Call Center/Telephony Configuration (set up, # phones/skills, reporting) 1/1/2019 3/30/2019 On Schedule

Finalize training modules 2/15/2019 3/15/2019 On Schedule Complete Training 4/1/2019 6/30/2019 On Schedule Clinical criteria developed/adopted and approved by QI/UM Committees 1/1/2019 3/30/2019 On Schedule

11. HSD will assess for approval all proposed delegated/subcontracted functions. Provide a list of those functions (e.g., Utilization Management, non-risk-bearing Behavioral Health) that your organization proposes to delegate (subcontract). List all proposed subcontractors that will perform services to Members and Providers and/or processing Medicaid business, including administration and systems functions. APCG has not yet identified any specific subcontractors or services that may be delegated at the time of our response to this RFI. We acknowledge and will comply with the requirements as outlined in the Centennial Care 2.0 contract requirements regarding delegation of services and subcontractors, including limitations regarding delegation of behavioral health services and member service functions and will seek prior approval from HSD prior to delegating/ subcontracting functions within the scope of an IMCE contract. We acknowledge and will maintain sole responsibility for the performance and oversight of all subcontracted functions. 12. Please describe your organization’s strategy and timeframe for establishment of the provider network. The response shall include how your organization will build a sufficient provider network that specifically addresses the needs of the following populations: Individuals with mental health and/or substance abuse issues; Children and adolescents; Persons with a comorbid physical, mental health and substance use conditions; Linguistic and cultural minorities; and Persons who need Long Term Services & Supports (LTSS) including Home and Community Based Services (HCBS).

BUILDING UPON A WELL ESTABLISHED NETWORK FOUNDATION

To ensure a culturally competent, comprehensive provider network, APCG and its 19 Pueblos Entity will build upon its foundational network and infrastructure by capturing, organizing and


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utilizing existing health care services, including physical health, behavioral health and long-term services and supports providers, currently operated by many of the Pueblos. This foundational network is inclusive of Indian Health Services, Tribal providers and the few Urban Indian Health Centers in and about New Mexico (see Attachment.2_I/T/U Provider Network). In addition, through the strategic partnership that is being established with a national managed care organization, the 19 Pueblos Entity will work diligently to gain access to care and to support its foundational network by contracting a provider network outside of tribal health systems. The contracts will be entered into by and between the 19 Pueblos Entity and the provider(s). For example, we will contract with safety net and other Medicaid providers in our service area, such as CHRISTUS St. Vincent (CHRISTUS) and the University of New Mexico (UNM), as well as the Primary Care Association (PCA) and its member organizations, including Presbyterian Medical Services (PMS), who is currently contracting for and providing services to Native American communities including services that are culturally competent and represent the desired faith healing and alternative care. APCG has already begun forming innovative partnerships with key provider organizations. For instance, UNM has not only indicated intent to participate as an in-network partner, but offered to explore placing staffed clinics and other medical services and resources on tribal land to fill care gaps and help ensure the success of APCG’s IMCE. APCG and UNM have also discussed education and training opportunities inclusive of a Project ECHO implementation, as well as ways to expand the capacity of UNM’s Center for Development and Disability to serve Native American members. The 19 Pueblos Entity recognizes and anticipates the possibility of serving members from non-Pueblo tribes. The 19 Pueblos Entity’s goal is to develop an adequate network able to serve all Native American members. Our unique value proposition includes the intent to develop a network upon the foundation of community-based services, education, training and full utilization of the Community Health Representative model for all populations. The 19 Pueblos Entity network will help members manage lifestyle factors and take responsibility for their healthcare decisions by advancing a preventative care model in partnership with our network providers. This approach will not only empower members, but serve to enhance the broader community. Additionally, our network development strategy includes:

• A local Provider Relations and Services team that will work closely with providers, especially those less familiar with managed care, to provide training and education and to alleviate administrative burdens.

• Partnerships with New Mexico providers and stakeholders who will participate in, and lead many aspects of Integrated Care Coordination (ICC) and member engagement,


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including delegated functions, Value-Based Purchasing (VBP), shared risk and savings, increased access across the delivery system, timely appointments and care, coordination and integration across disciplines, and evaluation.

TIMEFRAME FOR ESTABLISHMENT OF THE PROVIDER NETWORK

Through our strategic partnership with a national managed care entity and through our existing tribal health care service operations, we have already established strong partnerships with key providers and facilities and are ready to begin building a comprehensive provider network. Upon contract award, we will begin contracting a provider network that will assure access to all required services, including critical access providers, coordinated physical health (PH) and behavioral health (BH) services, as well as long-term services and supports (LTSS) throughout our service area. To quickly deliver a comprehensive provider network, we will leverage existing relationships with providers, associations and other stakeholders, as well as all available data sources, to identify network gaps, develop and execute a high-touch recruitment strategy and ensure expedient completion of application and credentialing processes. We will maintain timely access to care and network adequacy by monitoring and addressing network gaps and compliance with access and availability standards, and retaining the existing network through promotion of provider satisfaction. Our strategies for monitoring availability and timely access include: • Reviewing and analyzing geo-maps and capacity reports to ensure access to care and

provider capacity • Assessing provider to member ratios, appointment availability, and wait time audits to

continuously evolve and improve our network • Understanding patterns of care and out-of-network and out-of-state utilization and using

SCAs as applicable to ensure continuity of care • Understanding member complaints and stakeholder feedback to enhance and improve our

network

Additionally, the 19 Pueblos Entity will address gaps by expanding the use of telehealth, offering training and technical assistance to build capacity, partnering with universities and community colleges to support workforce development, incentivizing services in rural and frontier communities, and working with community agencies to identify and support social determinants of health and alternative care options. Additionally, the 19 Pueblos Entity will promote provider satisfaction through our local Provider Engagement Model, assigning every provider a single point of contact for all concerns.


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a. Individuals with mental health and/or substance abuse issues; The 19 Pueblos Entity will build a behavioral health (BH) network based on the New Mexico Behavioral Health Collaborative (BHC) vision of a coordinated, holistic, culturally competent system of care. We recognize the significant change in the BH system over the past four years and are committed to engaging existing providers to build permanent solutions to access, capacity, and workforce development. • We will convene Provider Advisory and Member Advisory Boards to gain input into the

decisions that affect the BH landscape in each Native American community. • We will offer Practice Coaches specializing in BH services. Our Practice Coaches will be

supported by our Claims Department, Encounters Team, Provider Engagement, and Network Management, to streamline data and claims issues with our NM BH providers.

• To further strengthen our network, we will actively promote CareLink NM Health Homes (CareLink), Treat First, Collaborative Care, and the use of Certified Peer Support Workers (CPSWs)

• To optimize and expand network capacity, we will increase the availability of step down services, incentivize reserved times for urgent/emergent and post crisis appointments, expand efforts to provide appropriate BH services via telehealth, leverage our partnership with UNM to further expand access through their Psychiatry Residency Training Program, recruit and retain new providers, and support and attract providers through VBP.

• The 19 Pueblos Entity will build upon its strategic partner’s existing provider relationships intended to leverage the strengths and capabilities of key New Mexico provider and stakeholders. For example, we will support UNM’s Psychiatry Residency Training Program to recruit and retain new providers. To ensure smooth transitions and effective recovery planning for those who need residential treatment we will seek to partner with providers including Hoy Recovery in Velarde, Santa Fe Recovery Center, Mental Health Resources (MHR) in Clovis and Four Winds Recovery Center in Farmington. Finally, we will work with Falling Colors in Santa Fe to ensure members have information about the non-Medicaid BH resources across the state, including SAPT Block Grant funded services and other federal and state grants and initiatives to reduce silos and allow for better, coordinated access.

• As NM’s rate of opiate mortality is among the highest in the nation, with Rio Arriba County particularly affected by heroin overdoses, we will work closely with substance use providers, the BH Collaborative, and national experts to address the opioid epidemic with leading edge evidence-based practices. Through our strategic partnership, we will work with Duke City Recovery Tool Box in ABQ, NM Treatment Services in Espanola, Courageous Transformations in Albuquerque, and others, to deploy a comprehensive strategy for prevention, treatment, and recovery. Provider engagement is a key strategy of our Opioid Program, which will promote use of NM’s Prescription Monitoring Program (PMP), offer expanded access to Medication Assisted Treatment (MAT) with therapy support and include provider profiling reports highlighting prescribing patterns, guidelines for appropriate prescribing practices and member and provider engagement templates.


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b. Children and adolescents; To effectively combat issues that affect many Native American communities, such as high rates of childhood obesity and Type 2 Diabetes, the 19 Pueblos Entity will address the social, economic and environmental determinates that shape children’s’ health. Our planned approach includes: • Training for all providers on EPSDT requirements and the importance of developmental

screenings • A partnership with the NM Alliance for School-Based Health Care to prevent health-related

absences, address social determinants of health (SDOH) and connect students to community resources

• As the child welfare population requires a specialized network approach, the 19 Pueblos Entity will work directly with child placement agencies, solicit input from foster parents and advocates like the New Mexico Tribal Indian Children Welfare Consortium, partner with the existing network of Medicaid and non-Medicaid organizations serving child welfare clients today, build a network for Therapeutic Foster Care and contract with multi-specialty practices to support children with special health care needs to build a system of care supported by the 19 Pueblos Entity training, technical support, and funding, as appropriate.

c. Persons with a comorbid physical, mental health and substance use conditions; Effective management of co-morbidities requires physical and behavioral health integration at the point of care. In addition to increasing the availability of BH in PH practices and better equipping Primary Care Providers to care for members with co-morbidities, we will support integration of PH resources into BH practices, make connections through VBP programs and leverage telemedicine. We will leverage local resources like Project ECHO and CareLink Health Homes, which include PMS, MHR and the eight additional providers projected to implement the program in 2018. We recognize and will contract with the many NM FQHCs who have enhanced BH programs and are an important source of BH care across the state. For example, First Choice in ABQ employs full time behaviorists at all nine clinic sites and half of PMS’s FQHCs are dually certified as CMHCs. Additionally, we will leverage the intensive substance abuse outpatient services provided by First Nations Community Healthsource, which is an Urban Indian Health Center as well as an FQHC. To expand these efforts, we will work closely with the PCA, PMS and UNM to support practice integration and the development and adoption of evidence-based integration models. We will incentivize integration through VBP contracts and support provider and community trainings through our strategic partner, including Mental Health First Aid; Patient-Centered Care; SBIRT; and Trauma Informed Care.

d. Linguistic and cultural minorities; and The 19 Pueblos Entity will contract with a network of providers that reflects our members’ cultural and linguistic needs, which will be formally evaluated at least annually. Culture contributes to identity and is influenced by race, language, ethnicity, and tribal identity, as well


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as disability, gender, sexual orientation and shared life experiences such as trauma, poverty, homelessness, health literacy, education, and occupation. Understanding how these factors affect utilization is critical to providing culturally sensitive and responsive care to our Native American communities. Strategies to support a culturally competent network include training, targeted recruitment, easy access to interpreter services, culturally competent programs and materials, and appropriate monitoring. Additionally, we will leverage resources throughout our 19 partner Pueblos to ensure materials are accurately translated into different tribal languages and dialects as allowed by tribal custom. e. Persons who need LTSS including Home and Community Based Services (HCBS). We will promote member choice and community integration by including a comprehensive set of LTSS and HCBS providers in our network. In addition to our own Pueblo based LTSS services (e.g., Laguna Pueblo’s Rainbow Nursing Center and Taos Living Center), we will work with nursing facility/assisted living providers across our service area such as but not limited to Genesis HealthCare and OnPointe Health and personal care service agency networks such as Options Home Care (Options), Ambercare, Consumer Direct, and Your Care Adult Day Services. We will seek to engage multiple partners to help us build a robust LTSS network in NM to increase choice and access to community-based services: • NM Health Care Association for Long Term Care Providers and NM Association for Home

and Hospice Care • NM Direct Caregivers Coalition • Self-Directed Providers Association • Area Agencies on Aging (AAAs) (including the Indian Area Agency on Aging) • Centers for Independent Living (CILs) In addition to building an LTSS provider network, we will enhance the competency of our overall network through trainings specific to coordination of acute care services for members with IDD, as well as disability sensitivity training. Through our strategic partner we will work with the AAAs and the local CILs to enhance access, facilitate nursing facility transitions, and support members in the least restrictive setting of their choice. We will also provide regular trainings for LTSS providers to assist with claims submission, authorization and EVV functions. 13. Describe your organization’s strategies for dealing with the challenges of building a provider network for rural and frontier parts of New Mexico; the strategy should address retention and recruitment efforts for primary care and specialists and availability of critical access providers such as Federally Qualified Health Centers (FQHCs), Nursing Facilities (NFs) and Non-Emergency Medical Transportation (NEMT) providers. In consideration of the federal requirements at 42 CFR 438.14 for payment to Indian Health Care Providers (IHCPs) and freedom of choice for Native American enrollees to receive care out of network, describe your organization’s strategies to secure in-network status for Indian Health Services, Tribally Operated Facilities or Programs, and Urban Indian Clinics (I/T/Us) to improve care coordination and member outcomes.


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ADDRESSING RURAL AND FRONTIER CHALLENGES The 19 Pueblos Entity’s effort to contract with other providers to address rural and frontier challenges, including Federally Qualified Health Centers (FQHCs), Nursing Facilities (NFs) and Non-Emergency Medical Transportation (NEMT), will be aided by our strategic partnership with a national Medicaid Managed Care Organization. The 19 Pueblos Entity will draw upon best practices to build a robust network in NM that accounts for challenges including, but not limited to, geography, available workforce, limited transportation, connectivity, and culturally/ linguistically responsive providers. Examples of our comprehensive strategy include: • A Native American Liaison program to ensure that all care delivered by non-I/T/U is

culturally competent and appropriate. Non-I/T/U providers will be required to participate in cultural competency training as a part of our network onboarding process, and additional trainings in partnership with tribes and IHS will be made available on an ongoing basis.

• Planning sessions with key providers like UNM, PMS, PHS, IPAs, the PCA and its members, CHRISTUS, and tribal leaders

• Existing commitment from UNM to open clinics in tribal areas to help build out tribal health systems as directed by the tribes

• Face-to-face engagement with rural and frontier providers to understand challenges, collaborate on solutions, and offer training, tools, technical assistance, and incentives. For example, providers have shared a need for timely access to actionable data and information, which our technology solutions and robust analytics will deliver at the point of care

• Implementing innovative VBP programs that address the unique challenges of providers with smaller patient panels. Many rural and tribal providers lack the scale and resources to invest in the infrastructure needed (capital, space, staff, IT, and time) to participate in meaningful VBP

• Leveraging the reach of CHRs through partnerships such as UNM and NM/Southern Colorado CHR Association, we can quickly expand education, certification, training, and utilization

• Developing and partnering with existing first responder training and community paramedicine programs to better triage and assess members for the most appropriate service, including home visits

• Partnering with the NM Alliance for School-Based Health Care and their School-Based Health Centers to promote comprehensive services to students in their school

• Using and incentivizing traveling specialists and mobile vans • Implementing a robust telehealth program including partnerships with UNM, PMS, and

MHR • Ensuring members have access to technology and can effectively communicate in no or low

tech areas. For example, installing kiosks in senior centers and tribal community centers, and providing high risk members with free landlines through our Care Grant program or hot spot enabled smart phones


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• Implementing a virtual visit option providing 24/7 access to board certified practitioners; Members can speak directly to a licensed doctor, from the convenience of their home or any location with phone or internet access, using web, phone or mobile app

• Addressing rural member access through transportation solutions including “Friends and Family”, volunteer drivers, and ride share options

Additionally, the 19 Pueblos Entity will develop retention and recruitment strategies to ensure access to care regardless of location: • Retention and Recruitment of Primary Care. According to the NM State Health

Assessment (2014), NM has 94 primary health professional shortage areas (HPSA) with 40.5% of the population living in a primary care HPSA, compared to 19.1% of the U.S. population. Our strategies to address this gap include partnerships with colleges and universities and incentive programs to attract and retain PCPs in these shortage areas. UNM has already committed to opening clinics in tribal areas to help build out tribal health systems, independent of or in conjunction with IHS.

• Retention and Recruitment of Specialty Care. Specialty shortages exist across NM, particularly in the area of BH. While in many areas these providers simply don’t exist, we will work with our strategic partner to bring services into underserved areas through telehealth, VBP, and partnerships with colleges and universities.

• Access to NEMT. Transportation is recognized as a critical issue across most of NM. We are in the process of identifying transportation vendors to build the right network of transportation providers that is accessible in rural and frontier areas, offers cultural and linguistic competence, and can meet the needs of members with complex health conditions. We will focus on rural transportation challenges with our transportation broker, requiring they contract with local and tribal transportation providers. We know that in tribal communities, many transportation services for Native Americans are provided by CHRs and Senior Centers. Some tribes also have their own transportation systems, including the Laguna Pueblo which has its own busing system and Navajo which has two transportation companies that are native owned. To build out a transportation network in rural and frontier areas, we will recruit providers and drivers interested in expanding their businesses, and explore volunteer driver options using “Certified Community Drivers” and independent contractors who meet all credentialing criteria. This could include Senior Companion Program volunteers that currently transport members to health care appointments. When available and appropriate, we will arrange for public transportation (e.g., commercial bus services) and expand access through our “Friends and Family” program that provides mileage reimbursement to a family member or friend. For emergencies, we will direct members to call 911 to access any available network or non-network emergency response provider. Finally, with HSD approval, we will explore the feasibility of offering ride-sharing options, such as Lyft or Uber, which can improve wait times for urgent trips and provide an option for


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“recovery” trips when the originally scheduled driver is delayed or unable to wait for a client whose appointment is delayed.

STRATEGIES TO SECURE IN-NETWORK STATUS FOR I/T/Us In accordance with 42 CFR § 438.14 Native American members will be automatically authorized to seek care from any I/T/U whether or not the I/T/U is a contracted provider, in order to support member freedom of choice and ensure continuity of care. However, to ensure coordinated, integrated care and to improve outcomes, the 19 Pueblos Entity is committed to signing agreements with all New Mexico I/T/Us, including I/T/Us that are not currently Medicaid providers, and to maintaining compliance with the payment terms established in 42 CFR § 438.14. Working through tribal leadership will allow the 19 Pueblos Entity to effectively address I/T/U concerns, such as the perception that accepting Medicaid will jeopardize their status under the federal Indian trust responsibility, and expediently build a network that conforms to the needs of the Native American population, rather than one that expects them to conform to the traditional health care system. Ongoing care coordination will be supported by tribal Community Health Representatives (CHRs), who already provide health promotion and disease prevention information, referrals, and services aimed supporting the health and wellness of Native American members and the tribal community overall. CHRs will serve an important role in addressing cultural barriers, conducting outreach with hard to reach members, and assisting members with linkages to social service supports for the full array of issues affecting health and wellness, including social determinants of health. The 19 Pueblos Entity will partner with tribes throughout New Mexico to recruit, educate and provide ongoing training to CHRs to ensure coordination of care for all members, regardless of location. 14. Describe your organization’s strategies for addressing contracted provider issues including oversight and monitoring of: a. Compliance with access standards; b. Provider network adequacy; c. Provider appeals and grievances; and d. Provider compliance with HSD Rules as outlined in the New Mexico Administrative Code (NMAC). The 19 Pueblos Entity’s Provider Network Management and Contracting (NM&C) department, led by our VP of NM&C, will be responsible for monitoring and addressing contract provider issues. We will use a local, on-the-ground, team-based approach, while leveraging our strategic partner’s support functions and tools such as state of the art information technology. Driving the ongoing activities of NM&C will be an HSD-approved comprehensive Provider Network Development and Management Plan. We will continuously evaluate our IMCE network for compliance with Centennial Care 2.0 Contract requirements, including access and availability standards based on member


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demographics and identified community needs; established patterns of care; provider satisfaction; and overall provider quality, performance, and clinical outcomes. During implementation, we will complete daily, monthly, and quarterly assessments to proactively identify problems, risks, and areas for additional recruitment; soliciting input from key provider partners, HSD, and advocates. We will have formal policies and procedures (P&Ps) describing management and monitoring activities, such as our Appointment and Accessibility Standards policy. This policy defines the accessibility standards applicable to contracted providers and describes the methods to monitor full compliance, including corrective action plans (CAPs) for provider noncompliance and methods for educating both members and providers about appointment standards. All P&Ps will comply with the Contract and regulatory requirements. a. Compliance with access standards; The 19 Pueblos Entity will meet all availability, time, and distance standards. We will have systems and processes in place to track and report this data, leveraging our strategic partner’s analytics system and keeping HSD informed of compliance. Our strategic partner’s experience with monitoring compliance with access standards includes, but is not limited to, reviewing and analyzing geo-mapping and network adequacy and capacity reports, provider to member ratios, appointment availability and wait time audit data (e.g. secret shopper surveys), patterns of care, use of Single Case Agreements (SCAs), member complaint data, member and provider feedback from a variety of sources, internal feedback from staff across all functions, utilization data, and compliance with language competency and American with Disability Act standards. Using this information, we will develop and monitor interventions for improving access, such as: • Developing targeted recruitment strategies and work plans to ensure that the 19 Pueblos

Entity contracts with providers and systems who can and will meet the PH, BH, LTSS, social, cultural, and linguistic needs of our members in all areas

• Issuing and monitoring provider CAPs for non-compliance with access standards, such as appointment availability and wait times while providing technical assistance and training to cure

• Expanding capacity through telemedicine • Providing training and technical assistance around practice transformation, including flexible

scheduling, appointment reminders, and other initiatives to reduce no-shows • Implementing provider tools such as our Appointment Wizard which will allow our staff to

schedule provider appointments with built in text appointment reminders • Employing our automated provider data management accuracy tools to validate provider

demographic data to ensure current, accurate, and clean data is on file for all contracted providers, including whether the provider’s practice is open or closed

• Contracting strategies and VBP to encourage providers to contract with the 19 Pueblos Entity, open panels, or offer expanded access such as extended hours, including evenings and weekends


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b. Provider network adequacy; Our Network/Contract and QI teams will monitor and evaluate provider network adequacy in multiple ways. Access is a significant issue in NM, and one that requires maximum provider participation, member engagement, and use of community resources. Based on identified gaps, member needs, changes in State/federal requirements, and stakeholder input, we will continue to develop and manage a targeted list of providers and partnerships to pursue and support as needed. This includes strategic and aligned provider partnerships centered on VBP, practice transformation, and integration. The 19 Pueblos Entity will leverage existing Indian Health Service providers and 638 Tribal providers as well as partnerships with PMS, UNM, and CHRISTUS to prioritize our target list to ensure a focused, high-touch effort to recruit high demand and specialized providers. Other strategies to ensure members receive services include: • Issuing Single Case Agreements (SCAs). We will issue SCAs with non-network providers

when in-network care is not available; attempting to recruit providers with a SCA • Leveraging Provider Champions. We will work with key local providers and partners, such

as the PCA and UNM to support recruiting for network expansion. • Implementing Financial Incentives. We will establish a continuum of VBP arrangements

with multiple provider types, including quality and access-based programs, tying incentives to a minimum performance against key quality and/or access metrics, such as increasing panel size, adding evening/weekend appointment availability or encouraging providers to expand competency through evidence-based trainings to treat members with special needs.

• Non-Financial Incentives. We will offer non-financial incentives, such as preferential member assignment (for members without an established PCP relationship) to providers who are in the top tier of quality performance.

• Workforce Development. We will collaborate with existing efforts to expand the workforce in size and scope, including transformation support; supporting internships and residency programs; and funding training and certification programs for CPSWs, CHWs, and CHRs.

• Telehealth. We will use telehealth to increase access in underserved specialties and areas.

c. Provider appeals and grievances; The 19 Pueblos Entity will strive to establish robust provider relationships that will result in strong provider satisfaction throughout our network. We will work collaboratively with providers to design, monitor, and achieve operational excellence for all our plan operations, including provider services and provider relations. We will maintain a formal Grievance system that is responsive to members and providers, in compliance with all HSD contractual and regulatory requirements, all applicable state and federal requirements, including but not limited to 42 CFR 438.406 and 438.408, as well as NCQA Accreditation Standards. Our Grievance System will consist of processes for complaints, grievances, and appeals and will be overseen by our Grievance and Appeals (G&A) Coordinator who will report to our QI Director, both of whom will be located in NM. Our G&A Coordinator and QI Department will


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track provider complaints/grievances by type, location, and region to identify trends indicating potential areas in need of further analysis and intervention. Providers will be able to file a Grievance orally or in writing. Grievances will be logged in our Customer Relationship Management (CRM) system describing the issue, date filed, and the dates and actions taken, and the final resolution. The G&A Coordinator will review and investigate the Grievance and issue a written notice of resolution letter to the provider within 30 calendar days. Our G&A Coordinator will monitor “inquiry age” within our CRM system to ensure adherence to resolution timeliness. However, if the Grievance is not resolved in 30 days, the G&A Coordinator will request a 14 day extension from the provider. If the provider requests the extension, the extension will be approved. Providers will be able to file an Appeal regarding provider payment issues and/or Utilization Management decisions. Appeals may be submitted orally or in writing within 60 calendar days of receiving the notice of Adverse Benefit Determination. The G&A Coordinator will log the appeal within CRM. If the appeal is related to a medical determination, the G&A Coordinator will route the Appeal through our clinical documentation system to a physician who did not participate in the original review and denial of the service. If the Appeal is related to a payment decision the G&A Coordinator will investigate the Appeal and make a determination. The G&A Coordinator will review and investigate the Grievance and issue a written notice of resolution letter to the provider within 30 calendar days unless an extension is warranted in accordance with 42 CFR 438.408. Expedited Appeals related to medical necessity determinations will be resolved within 72 hours of receipt of the appeal. d. Provider compliance with HSD Rules and the New Mexico Administrative Code (NMAC). We will contractually require providers to comply with HSD Rules and the NMAC. Requirements will be explained and reinforced in provider orientations, ongoing provider trainings and updates, and in the Provider Manual. We will monitor compliance through annual audits, including access and appointment availability, analysis of claims and provider billing practices, monitoring of member and provider grievance and appeals, and a review of relevant provider reports including out of network provider utilization. Failure to comply will result in a CAP, with subsequent training to help providers regain and maintain compliance. Continued failure to comply could result in network termination, in accordance with contract requirements. 15. Submit detailed flowcharts, narrative descriptions, and operation manuals of your organization’s existing or planned systems to meet the requirements in the Centennial Care 2.0 contract and in the Centennial Care Systems Manual, addressing – at a minimum – the functional areas listed below. Your narrative response shall describe the extent to which these systems are: (i) currently implemented as opposed to planned; and (ii) integrated (or planned to be integrated) with other systems, internal and external. a. Eligibility, enrollment, and disenrollment management and data exchange; b. Provider network management, certification, enrollment, notification and confirmation file exchange; c. Member and provider information access; d. Report generation and transmission;


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e. Care coordination system; f. Nursing facility level and setting of care assessments, determination, tracking, and communicating; g. Claims processing, edits, corrections, and adjustments due to retroactive eligibility changes or other reasons; h. Claims adjudication, payment, and coordination of benefits for claims with third party liability and Medicare; i. Systems modules to track and administer different Medicaid benefit packages, copays, and premiums; j. Encounter submissions, correction, voiding, and resubmission; k. Financial management and accounting activities; and l. Provider technical assistance for I/T/Us, Rural Health Clinics, FQHCs, NFs as well as other specialty providers.

MANAGEMENT INFORMATION SYSTEM READY FOR CENTENNIAL CARE 2.0

The 19 Pueblo Entity will leverage our strategic partner’s existing enterprise MIS that supports PH, BH, and LTSS for Medicaid members nationwide. This existing MIS ensures that the 19 Pueblo Entity will meet the Sample Contract requirements outlined in the Centennial Care 2.0 Contract and the Centennial Care System Manual, and is in compliance with the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health Act (HITECH), Section 6504(a) of the Affordable Care Act, and applicable state and federal laws and regulations. This interoperable MIS, integrated via Service Oriented Architecture (SOA) is a design informed by the Centers for Medicare & Medicaid Services’ (CMS) Medicaid Information Technology Architecture (MITA), enables us to exceed Centennial Care 2.0 program requirements. Experience Implementing and Operating in Other States. Our strategic partner has been accountable to state agencies across the nation for operational readiness prior to the successful implementation of Medicaid health plans with integrated PH, BH, and LTSS. Their expertise is reflected in an ability to nimbly configure MIS changes to meet new and evolving program requirements and capacity demands in support of implementing and operating government-sponsored healthcare programs across the country. Together, the 19 Pueblos Entity and our strategic partner will leverage experience, lessons learned, best practices and a transparent approach to implement and operate the Centennial Care 2.0 program. Upon finalization of our strategic partnerships and as part of any subsequent RFP or request to negotiate resultant from this RFI, the 19 Pueblos Health Entity will submit detailed flowcharts, narrative descriptions, and operation manuals of our MIS to support our IMCE as part of the Centennial Care 2.0 program. 16. Describe how your organization will establish special provider reimbursement systems and claims submission capability, including but not limited to: a. Ability to make special payments to unique providers, such as FQHCs and I/T/Us, including contracted and non-contracted where applicable; b. Experience in processing claims for Medicare clients and providing Medicare encounter data in HIPAA- compliant formats to federal and state authorities.

ESTABLISHING SPECIAL PROVIDER REIMBURSEMENT SYSTEMS


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As noted above, the 19 Pueblos Entity will form a strategic partnership with a national Medicaid managed care organization whose claims processing system currently allows for customized configuration – at the individual contract or provider level – to support special provider reimbursement models in alignment with all Special Reimbursement Requirements including reimbursement for unique providers types (FQHCs, RHCs, I/T/Us, family planning providers), whether in network (contracted) or out-of-network (non-contracted). We will also configure our claims system to reimburse NM’s FMA for authorized self-directed community benefit (SDCB) services at the appropriate rate for the self-directed Community Benefit and applicable payroll taxes. We will ensure accurate claims payment for all special types of provider reimbursements such as accurate payment when members disenroll while hospitalized, pharmacy services payments and emergency services payments. The claims system supports special provider reimbursements and payments beyond traditional FFS payments, including partial and global capitation and shared savings payments. Payment guides created in the claims system will guide the configuration of payment arrangements in our contract modeling and provider pricing tools. Our contract modeling and pricing tools include contract simulation capabilities that will allow us to configure and load complex provider reimbursement schedules into the claims system, enabling the our provider network team to predict the effect of the total reimbursement schedule (including payments for direct care service, as well as care coordination activities) on network providers. These capabilities ensure that we will incent our providers appropriately to deliver coordinated care, without exposing providers to unacceptable risk levels, and that, as we track quality and coordinated care measures, we are able to adjust our reimbursement strategy to incent quality care.

CLAIMS SUBMISSION CAPABILITY

The 19 Pueblos Entity and its strategic partner understands that effective with the implementation of the MMIS-R, providers and applicable subcontractors will submit claims directly to the SI. Any claims we receive from providers and subcontractors directly will be rejected and redirected to the SI. Our contracts will require proper claim submission to the SI, including electronic submission for our Major Subcontractors. To alleviate provider abrasion, our provider engagement staff will provide training and ongoing assistance to onboard and educate providers on how to submit claims on the SI through onsite and remote training (e.g., webinars). In addition, we have the flexibility to accommodate multiple claims submission options if the MMIS-R is not implemented by Go-Live. In this scenario, we can accommodate flexible claims submission options, including: submission of HIPAA 837 EDI claims through more than 85 claims clearinghouses; through our secure Provider Portal; submission through a multi-payer portal; and receipt of paper claims. a. Ability to make special payments to unique providers, such as FQHCs and I/T/Us, including contracted and non-contracted where applicable;


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Our Claims Configuration Manager will create separate payment guides, which will specify the configuration of payment arrangements in the claims system for special payments to unique providers and special reimbursement types including:

Unique Providers

Configured Payment Guides in the claims system

FQHCs & RHCs

Payment guides configured in the claims system ensure reimbursement at a minimum of the Prospective Payment System (PPS) or alternate payment method for contracted and non-contracted providers

I/T/Us

Payment guides configured in the claims system will reimburse both contract and non-contract provider I/T/Us at a minimum of one hundred percent (100%) of the rate currently established for the IHS facilities or federally leased facilities by the Office of Management and Budget (OMB) • If a rate is not established by OMB for any particular service, we will reimburse at an amount

no less than the Medicaid fee schedule. We acknowledge that services provided within I/T/Us will not be subject to prior authorization requirements

Non-contract providers

Payment guides configured in the claims system will ensure: • Proper reimbursement for Family Planning at the rate set by HSD • Proper reimbursement for women in the third trimester, which we will reimburse in accordance

with the Medicaid fee schedule appropriate to the provider type • Proper reimbursement for non-contract providers reimbursed at 95% of Medicaid fee schedule

rate • Proper reimbursement for non-contract NFs reimbursed at 100% of Medicaid fee schedule rate

b. Experience in processing claims for Medicare clients and providing Medicare encounter data in HIPAA- compliant formats to federal and state authorities. The 19 Pueblos Entity will leverage the experience of our strategic partner who currently processes Medicare claims and provides Medicare encounter data on behalf of Medicare-Medicaid Program (MMP), D-SNP and Medicare Advantage (MA) members. Our strategic partner is recognized as a leader in Medicare encounter data performance. 17. Describe your organization’s vision for the care coordination program, including the software and systems to be utilized.

ORGANIZATIONAL VISION FOR THE CARE COORDINATION PROGRAM The 19 Pueblos Entity’s vision for our Care Coordination Program is to deliver services that are person-centered and coordinate the full continuum of a member’s needs. The goal of our Care Coordination Program is to help Native American members achieve the highest possible levels of wellness, functioning, and quality of life. The 19 Pueblos Entity will accomplish this by treating the whole-person and integrating the physical health, behavioral health, long term services and supports, and social services the member needs to create a system of care around the member. This approach allows us to address not only the clinical needs of the member but also social determinants of health (SDOH) such as transportation, housing, food, employment, and other non-clinical needs that have an impact on health outcomes and quality of life for Native Americans. Our Care Coordination Program activities will be carried out by the 19 Pueblos


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Entity’s Care Coordination team, which will include nurses, licensed BH clinicians, pharmacist, Medical Director, Care Coordinators, and Community Health Representatives (CHRs). To the extent possible, the 19 Pueblos Entity will recruit and hire, or contract with, individuals that are local tribal members to be Care Coordinators (CCs), and will ensure compliance with the requirement that all members be assigned a Native American CC upon request. We recognize that with NM being home to 19 Pueblos, staffing multiple Native American CCs representative of each tribe will be a challenge. Therefore, our Native American Liaisons will work closely with the tribal leaders and I/T/Us to educate, train, recruit, and support local CCs and CHRs. CHRs will be central to our Care Coordination strategy for Native American members. CHRs will serve an important role in addressing cultural barriers, conducting outreach with hard to reach members, and assisting members with linkages to social service supports for the full array of issues impacting health and wellness, including SDOH. Care Coordination Program Elements. Our Care Coordination Program will be designed to provide care coordination services across the full continuum of care and achieve optimal health and quality outcomes through: • Member-centric and culturally-responsive coordinated care that encourages personal

responsibility and member engagement using Motivational Interviewing techniques • Predictive modeling data that identifies members at risk for future adverse events that can

benefit from care coordination activities • Health Screenings designed to stratify members into levels of care coordination and identify

each member’s whole person needs • Development of a care plan that addresses PH, BH and other needs that are responsive to

each member’s preferences and chosen goals • The 19 Pueblos Entity’s Care Coordination Program multi-disciplinary staff working

together with the member and their chosen circle of support, and providers to support member wellness across the continuum of care

• Software and system solutions (discussed in additional detail below) that support communication and care coordination among members of the Care Coordination Team, provider network, and other applicable entities

Role of the Care Coordinator. The 19 Pueblos Entity’s CCs will be licensed nurses or BH clinicians, depending on the primary needs of the member. We will assign members to a CC with expertise that matches their primary reason for care coordination. Our CC is responsible for working with the member on a one-on-one basis and their providers to identify needs. Once needs have been identified, our CC will work with the member develop a care plan to help the member achieve their identified goals. Care plans are adjusted based on changes in condition and/or status as well as evolving member goals. The 19 Pueblos Entity CCs and other clinical staff will consult with and/or seeks advice from the 19 Pueblos Entity medical directors,


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pharmacists or other specialists as indicated by the member’s needs. Care coordination activities that will be performed by the 19 Pueblos Entity CCs will include but not be limited to the activities in the table below. Care Coordination Activities • Provide culturally competent care with consideration of the member’s customs • Face to face and phone contact with members as appropriate (or as requested) • Work directly with providers with member participation • Provide ongoing care coordination services as needed • Resource linkage to address member needs such as but not limited to PH, BH, substance

use, tobacco cessation, housing needs, etc. • Connect members to needed providers based on their preferences • Follow-up as needed (or as clinically indicated) to develop solutions for member concerns

and/or barriers to care • Provide education about the 19 Pueblos Entity programs and benefits • Identify and address care gaps

Training. Through our strategic partner, the 19 Pueblos Entity will have fully developed training curriculums and access to clinical trainers with national experience to deliver tailored trainings to the 19 Pueblos Entity care coordination staff, providers, and community stakeholders. We will offer trainings on our Care Coordination framework and a range of topics that support our person-centered approach to care. The trainings that we will offer reflect the principles and practices that we strive toward in supporting our providers and communities in delivering person-centered, value-based care, such as but not limited to Trauma-Informed Care, Integrated Care, and Motivational Interviewing. We will embed these trainings into our curriculum so that all new providers and staff have the foundation to weave these practices into their service delivery.

SOFTWARE AND SYSTEMS TO BE UTILIZED Through our strategic partner, the 19 Pueblos Entity will use software and systems such as but not limited to the following to support care coordination activities: • Integrated Care Coordination Platform. The 19 Pueblos Entity’s strategic partner offers a

member-centric care coordination platform to support our care coordination work flow processes. This integrated care coordination platform will house assessment information and results for our members, including health screenings and other assessments for specific PH and BH conditions. The Platform will allow the 19 Pueblos Entity care coordination staff to administer straightforward assessments and offers a library of evidence-based care coordination interventions that can be custom tailored to the member’s needs. The Platform’s system functionality also allows for the collection and reporting of short term and intermediate outcomes, such as member risk level and acuity.


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• Predictive Modeling. The 19 Pueblos Entity will have access to its strategic partners proprietary predictive analytics platform that includes a suite of best-of-breed predictive modeling solutions incorporating evidence-based, proprietary care gap/health risk identification applications that identify and report significant health risks at population, member, and provider levels. These care gaps and health risk alerts power our online care gaps, which are visible in our care coordination platform – allowing our members and providers to securely access actionable health information via our secure web portals.

• Web Portals. We will facilitate information sharing across the system through online, secure portals. Through Member and Provider portals, authorized participants or approved users can access member clinical and care planning information such as completed assessments; shared care plans; PH and BH service history and screenings; lab results; and other clinical data, while maintaining the security and privacy of the member’s personal and protected information.

18. Describe your organization’s strategies for outreach to enroll and retain Native American members. Include in your description your approach for those enrolled in fee-for-service and also Centennial Care managed care.

OUTREACH STRATEGIES TO ENROLL AND RETAIN MEMBERS The 19 Pueblos Entity’s strategy for outreach includes a three pronged approach: 1) Providing educational materials 2) Operating a comprehensive Member Services and Care Coordination program and 3) Engaging members during different forms of outreach as needed to provide education about their options. Our outreach model is founded upon improving the accessibility and delivery of integrated healthcare solutions to Native American members while respecting member choice, tribal sovereignty, and tribal self-determination. Our approach for outreach to Native American members will include consideration of multiple factors including but not limited to: • We meet members where they are, going beyond traditional member services to give

members flexible options for connecting with the 19 Pueblos Entity • Our support will be individual, responsive, and ensures no wrong door • Providing person-centered care to each member with particular attention to their specific

tribe and individual needs/preferences • Providing member education to about their options in terms of coverage as well as education

about the benefits of being a 19 Pueblos Entity member • Hiring locally from within Tribal Nations and Pueblos to ensure members interact with

outreach staff that have shared experiences Educational Materials. The 19 Pueblos Entity will provide educational information to our Native American members and potential members through written materials (e.g., Member Handbook), telephone, internet (e.g., mobile applications and Member Portal), and face-to-face communications (e.g., health fairs, tribal community events and school-based education events), and ensure our materials identify differences among the categories of eligibility.


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Member Services. The 19 Pueblos Entity will operate a comprehensive Member Services program, which will provide educational support, ensuring meaningful and relevant member education and engagement, answering member inquiries, addressing member concerns, and improving the member experience. In addition, Member Services Representatives (MSRs) who are part of our Member Services program, will provide education and respond to enrollment telephonic inquiries from members and/or caregivers. MSRs will be trained and prepared to assist and our membership in a culturally competent manner including those who may have special needs including members for whom English is not their primary language. MSRs will educate and provide information to members on: • Enrollment options and eligibility • Covered services and how to appropriately access them • Accessing other health care services within the community • Submitting grievances or appeals • Reporting fraud or abuse • Locating a provider • Health crisis support • Balance billing issues • Cost-sharing and patient liability inquiries MSRs will be trained to identify enrollment and eligibility member issues. Through our strategic partner, the 19 Pueblos Entity MSRs will be supported by a Customer Relationship Management (CRM) system as well as a Member Orchestration platform that ensures our member outreach and engagement materials are disseminated to all members and potential members accurately, in the format that best meets their needs, including written materials, telephone, internet and face-to-face communications and identifies differences among the categories of eligibility to increase the retaining of members. In addition, the 19 Pueblos Entity will employ the following retaining practices to decrease potential disenrollment: • Ensure members have knowledge of all of their enrollment options and emphasizing member

choice • Ensure members are provided and have a direct contact number to the 19 Pueblos Entity

Member Services program • Ensure we provide written notice of any significant change in policies concerning member

disenrollment rights • Ensure the 19 Pueblos Entity makes information available in paper form and other formats to

meet member needs • Ensure all member information is posted electronically on our website and in such a format

that can be easily printed by members • Compliance with Contract requirements


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Member Engagement. Every engagement opportunity is leveraged to facilitate the next activity necessary to improve health and wellness for each member. Beyond Member Services and our call center, digital communication and social media will be used to outreach and effectively engage members based on each individual’s health profile, needs, and enrollment options. Through care coordination activities, we reach out to members multiple times, in multiple formats, and emphasize personalized contact based on the member’s needs and preferences. We supplement our general outreach and education with targeted, individualized approaches, such as reminders about appointments, and community-based events that are held in collaboration with trusted tribal entities, organizations, schools, and FQHCs.

MEMBERS ENROLLED IN FEE-FOR SERVICE

The 19 Pueblos Entity’s outreach approach for members enrolled in fee-for-service will be similar to the strategies described above. In addition, the 19 Pueblos Entity will host or attend open community forums and Tribal Collaboration Meetings to further provide education about the 19 Pueblos Entity benefits and programs. The 19 Pueblos Entity materials will be made available to members, when appropriate, at community events to ensure members have education information about the 19 Pueblos Entity’s programs and how we value shared experiences as a Native American owned organization.

MEMBERS ENROLLED IN CENTENNIAL CARE MANAGED CARE

The 19 Pueblos Entity’s outreach approach for Native American members enrolled in Centennial Care Managed Care will be similar to the strategies described above.


ATTACHMENT.1_Job Descriptions a. CEO of Centennial Care 2.0 CEO Job Description Position Purpose: Authorized to represent 19 Pueblos Entity regarding all matters pertaining to the Contract, the CEO will be fully dedicated to this position and will ensure that 19 Pueblos Entity functions at the highest level of efficiency and effectiveness. The CEO will serve a cross-functional strategic and oversight role, monitoring health plan performance, and planning and directing all aspects of the company’s operational policies, objectives, and initiatives. Education/Experience: Bachelor’s degree in Business, Health Care Administration, Public Administration or related field; Master’s degree preferred; five plus years of experience in a top management position in the government or healthcare industry; extensive experience in contracting, contract acquisition, operations management, and strategic planning and development; and previous experience managing staff, including hiring, training, and managing workload and performance. Responsibilities: Develops policies and procedures for operational processes in order to ensure optimization and compliance with established standards and regulations; represents the organization in its relationships with major customers, suppliers, competitors, commercial and investment bankers, government agencies, professional societies, and similar groups; develops a sound short-and long-range plan for the organization; ensures the adequacy and soundness of the organization’s financial structure and reviews projections of working capital requirements; negotiates and otherwise arranges for any outside financing that may be indicated. b. CFO of Centennial Care 2.0 CFO Job Description Position Purpose: Manage the monthly, quarterly and annual budgeting process for the entire Health Plans or Specialty Companies, including the review/analysis of detailed business unit budgets and the comparison to actual financial results. Education/Experience: Bachelor’s degree in Accounting or Finance; seven plus years of finance, accounting or budgeting experience; experience in the health care industry and/or public accounting preferred; fundamental understanding of financial planning systems along with advanced Excel/spreadsheet modeling a plus. License/Certificates: CPA preferred. Position Responsibilities: Monitor business processes and systems to assure integrity in information and systems; oversee preparation of accurate and timely financial reports; Responsible for accounting and finance operations, including all audit activities; review, communicate, and present strategic plans, operating budgets and forecasts; establish targets and

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 measures that are appropriate for the site and are directly linked to business unit and corporate objectives as well as evaluate program effectiveness and ensure reporting accuracy; provide financial plan for performance variances, operating alternatives, program and investment initiatives, etc.; interpret financial reports for management team; serve as contact for the State, corporate, and business unit functions regarding financial matters; monitor legislative and political developments affecting the business unit from a financial perspective; coordinate political contribution activity, interact with lobbyists, attend political fundraisers, and ensure compliance with political contribution statutes. c. CIO of Centennial Care 2.0 CIO Job Description Position Purpose: To plan, manage, and coordinate the development and operation of information systems or technology solutions to meet business needs. Education/Experience: Bachelor's degree in Computer Science, MIS, related field, or equivalent experience; five plus years of experience managing IT Operations; must have thorough knowledge of information systems technology, with emphasis in the managed care industry, including new product development, systems support and strategic planning; excellent knowledge of Microsoft networks environments, Microsoft SQL database applications, web services, EDI, telecommunications, security, and automation. Responsibilities: To oversee and be responsible for all of 19 Pueblos Entity’s information systems functions supporting this Agreement and manage department staff including the hiring, performance management, and career development to ensure alignment with defined goals; maintain existing enterprise systems, while providing direction in all technology related issues in support of information operations and company technology solutions objectives; liaison with managers in IT and other functions, applying standard solutions and processes; and apply specific technical expertise in depth to address technical and business issues. d. Implementation Manager Implementation Manager Job Description Position Purpose: To work with 19 Pueblos Entity and Centene Corporation to implement the 19 Pueblos Entity health plan according to all Contract requirements. This position will also assist in the final transition from implementation to operations by overseeing all related activities for new business implementation for assigned functions, including development of training materials, policies and procedures, and training for all business areas. Education/Experience: Bachelor’s degree in business, related field or equivalent experience; five plus years of health plan service operations (member/provider services, enrollment, provider data management, provider relations, or quality), and training experience; experience with State and

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 federal health programs, such as Medicaid and Medicare; highly motivated and self-directed with the capability to organize and execute projects; integrity, flexibility, and excellent interpersonal and communication skills; demonstrated business acumen with a capacity to think critically and strategically; strong leadership skills with the ability to foster them in others; resides in New Mexico from start of contract to at least six months after Go-Live date. Responsibilities: This full-time, dedicated manager will act as the primary on-site point of contact for all 19 Pueblos Entity operational issues from the start date of the Contract through at least six months after Go-Live or through the transition from the implementation team to regular on-going operations, this position requires fielding and coordinating responses to HSD inquiries prior to Go-Live; develop and maintain records of contracts, contract amendments, compliance measures and improvements, policy, procedure and process documentation; Develop policies, procedures and processes to comply with State law, federal law and State contract requirements; train 19 Pueblos Entity staff on new policies, procedures and processes to comply with State law, federal law and State contract requirements; work with all aspects of operations to identify, develop, and audit processes, standards, and programs for assigned function; develop all materials for new market implementations, including reference manual, reference guide, training materials, and policies and procedures; coordinate training curriculum and schedule for new hires and conduct related training in new markets; research and incorporate best practices into assigned function to streamline, organize, and improve the overall process workflows; monitor results to ensure exemplary service levels and return on investment; create effective organizational structure and develop staff skills and competencies through training and experience; manage activities related to various training and education programs, including assessing training program effectiveness, training needs, and improvement recommendations participate in the recruitment efforts and candidate selection process; serve as the market lead during implementation until local team is in place. e. Medical Directors Chief Medical Director Job Description Position Purpose: Assist the Chief Medical Officer to direct and coordinate the medical management, quality improvement, and credentialing functions for the business unit. Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics, or Emergency Medicine). The candidate must be an actively practicing physician, and previous experience within a managed care organization is preferred; course work in the areas of health administration, health financing, insurance, and/or personnel management is preferred; and experience treating or managing care for a culturally diverse population preferred. License/Certifications: Board Certification through American Board Medical Specialties, and a current state medical license without restrictions.

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 Responsibilities: Provides medical leadership (will be dedicated to this Agreement and will be licensed to practice medicine in the State of New Mexico) of all for utilization management, cost containment, and medical quality improvement activities; performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services; supports effective implementation of performance improvement initiatives for capitated providers; assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members; provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements; assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership; oversees the activities of physician advisors and uses medical and pharmacy consultants for reviewing complex cases and medical necessity appeals; participates in provider network development and new market expansion as appropriate; assists in the development and implementation of physician education with respect to clinical issues and policies; identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components; identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care; interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality; reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment; develops alliances with the provider community through the development and implementation of the medical management programs, and, as needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues; represents the business unit at appropriate state committees and other ad hoc committees. The Director, or his or her designee, will also be available by telephone 24 hours a day, 7 days a week, for utilization management decisions. BH Medical Director Job Description Position Purpose: To assist the Chief Medical Director/ to direct and coordinate the BH medical management, quality improvement, and credentialing functions for the business unit. Education/Experience: Must be a board- certified psychiatrist in the State of New Mexico, and must be an actively practicing physician, with at least five years of combined experience in mental health and substance abuse services and previous experience within a managed care organization is preferred; course work in the areas of health administration, health financing, insurance, and/or personnel management is preferred; and experience treating or managing care for a culturally diverse population preferred. License/Certifications: Board Certification through American Board Medical Specialties, and a current state medical license without restrictions.

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 Responsibilities: Will be a dedicated, full-time BH professional who will oversee and be responsible for all BH activities and take an active role in 19 Pueblos Entity’s BH medical management team and in clinical and policy decisions, including: providing BH medical leadership of all for utilization management, cost containment, and medical quality improvement activities; performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services; supports effective implementation of performance improvement initiatives for capitated providers; assists Chief Medical Director/Medical Director in planning and establishing BH goals and policies to improve quality and cost-effectiveness of care and service for members; provides BH medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements; assists the Chief Medical Director in the functioning of the physician committees, including committee structure, processes, and membership; oversees the activities of physician advisors and uses BH, medical, and pharmacy consultants for reviewing complex cases and medical necessity appeals; participates in provider network development and new market expansion as appropriate; assists in the development and implementation of physician education with respect to clinical issues and policies; identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components; identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care; interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve BH utilization and health care quality; reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment; develops alliances with the provider community through the development and implementation of the medical management programs, and, as needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues; represents the business unit at appropriate state and other ad hoc committees. f. Long-Term Services and Support Manager LTSS Manager Job Description Position Purpose: The LTSS Manager drives 19 Pueblos Entity’s LTSS programs’ overall strategy and oversees integrated medical, behavioral and social services for a large, complex program. The Director is responsible for the planning, implementation and oversight of 19 Pueblos Entity’s State Health Program services and LTSS program and will ensure all regulatory requirements are operationalized and complex compliance standards are met. Education/Experience: Bachelor’s degree in relevant field required, Master’s Degree in Public Health, Healthcare Administration, Business Administration, or clinical background preferred; minimum 10 years’ progressively responsible operations management experience; minimum five

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 years’ experience administering long term care programs and services, including Home and Community Based Services (or managed care experience can be substituted with HSD’s prior approval), minimum five years customer service and Medicare experience, plus experience in interacting with government agencies and senior populations preferred. Also, a minimum of 10 years’ experience managing budgets and overseeing managerial and supervisory staff. Geriatric and/or developmental disability experience preferred. License/Certification: Current and Valid Driver’s license to travel between worksites. Responsibilities: To oversee and be responsible for all LTSS activities; develop strategy and LTSS program for 19 Pueblos Entity; ensure 19 Pueblos Entity’s LTSS programs strategic objectives are developed and maintained through the development and implementation of work processes and operational systems; research changes and updates to government regulations and / or health plan guidelines; create a network development plan and integrate LTSS and other network providers; identify trends and root causes of issues / barriers / problems and provide recommendations for improvements, documentation, and training; participate in the integration of specialty products into 19 Pueblos Entity operations; and oversee both clinical and non-clinical direct reports. g. Contract Manager Contract Manager Job Description Position Purpose: Oversee the development and management of company products. Drive ongoing definition, integration, and enhancement of selected company products and assess the performance of existing products to ensure market expectations are met; this position will meet all requirements listed in Centennial Care 2.0 Contract, including being authorized and empowered to represent 19 Pueblos Entity on all matters pertaining to the health plan and this Agreement; act as a liaison between 19 Pueblos Entity, HSD, the Collaborative, and other State or federal agencies, as necessary, as well as all responsibilities listed for this position in the Centennial Care 2.0 Contract. Education/Experience: Bachelor's degree in related field, Master’s degree preferred; five plus years of product and services development and management, including experience with assigned product(s). Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience, including hiring, training, assigning work and managing the performance of staff. Responsibilities: Ensure 19 Pueblos Entity complies with the terms of the Agreement, including securing and coordinating resources necessary for such compliance; overseeing all activities by the 19 Pueblos Entity and its major subcontractors and subcontractors; receive and respond to all inquiries and requests by HSD, or any State or federal agency, in timeframes and formats reasonably acceptable to all parties; meet with representatives of HSD and other State agencies on a periodic or as-needed basis and resolving issues that arise; attend and participate in regular

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 meetings with HSD and other State agencies, and attend and participate in stakeholder meetings; make best efforts to promptly resolve any issues related to this Agreement identified by HSD, other State or federal agencies, or 19 Pueblos Entity; work cooperatively with other State of New Mexico contracting partners; work with, at the Collaborative’s direction, the BH Planning Council, and local BH collaboratives; work with the Non-Medicaid Contractor and / or the BH Collaborative in identifying the overall BH needs of Medicaid members to coordinate and obtain non-Medicaid services for those members, as appropriate; develop and have mutually agreed upon policies and procedures with Non-Medicaid contractors addressing areas such as information sharing, billing procedures and that contractor’s participation in non-Medicaid initiatives; identify opportunities to enhance existing products and services to improve clinical and financial performance to better align with competitive markets; design, develop; and manage new and existing products from initial conception through service delivery; monitor market trends to identify new product opportunities and enhancements to existing products; create detailed project plans, support product pricing efforts, and determine client reporting specifications; conduct brand development activities including the creation of product and population specific collateral materials; review product performance and outcomes based on cost and benefit analyses and make recommendations for product improvements; implement ongoing internal and external product trainings to improve product outcomes. Chief Operating Officer Position Purpose: Plans and directs all aspects of the Business Unit’s operations. Responsible for the short and long term profitability and growth of the Business Unit. Knowledge/Experience: Bachelor’s degree in Business, Health Care Administration, Public Administration or related field. Master’s degree preferred. 5+ years of experience in a top management position in the government or healthcare industry working on contract acquisition and operations management. Extensive experience in contracting and strategic planning and development. Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff. Competencies: Decision Making, Managed Care Experience, Partnership Approach, Personal Conduct, Process Improvement, Production Results, Q4 Leadership, Strategic Vision. Responsibilities: • Plans and directs all aspects of the company’s operational policies, objectives, and initiatives • Develops policies and procedures for operational processes in order to ensure optimization

and compliance with established standards and regulations • Represents the organization in its relationships with major customers, suppliers, competitors,

commercial and investment bankers, government agencies, professional societies, and similar groups

State of New Mexico Submitted by: Indian Managed Care Entity RFI All Pueblo Council of Governors March 2018 • Develops a sound short - and long- range plan for the organization • Ensures the adequacy and soundness of the organization’s financial structure and reviews

projections of working capital requirements. • Negotiates and otherwise arranges for any outside financing that may be indicated


ATTACHMENT.2_I/T/U Provider Network Indian Health Services Most IHS facilities provide: Primary Care, Laboratory, Public Health Nurse, Medical Imaging, Dental, Pharmacy, Well Child Care, Women’s Health. Direct Service Tribes usually do not have a facility on Reservation; patients have to travel off reservation to obtain services. Field Clinics typically only provided basic Primary care services and have limited operational hours. ACL and Santa Fe Indian hospitals have very limited inpatient care. Albuquerque Indian Health Center https://www.ihs.gov/Albuquerque/healthcarefacilities/albuquerque/

• Santa Ana field Clinic • Zia field Clinic

ACL Hospital https://www.ihs.gov/albuquerque/healthcarefacilities/acomacanoncitolaguna/ Zuni Hospital https://www.ihs.gov/Albuquerque/healthcarefacilities/zuniramah/ Taos/Picuris Service Unit https://www.ihs.gov/Albuquerque/healthcarefacilities/taospicuris/

• Taos Clinic • Picuris Direct Services

Santa Fe Indian Hospital https://www.ihs.gov/Albuquerque/healthcarefacilities/santafe/

• Cochiti field Clinic • San Felipe field Clinic • Nambe Direct Services • Tesuque Direct Services • Pojoaque Direct Services • San Ildefonso Direct Services • Santa Clara Field Clinic • Ohkay Owingeh Direct Services

First Nations Community Healthsource: Urban Indian Facility http://www.fnch.org Full service FQHC Contracted Services

• ENIPC inc. serves Nambe, San Ildefonso, Pojoaque, Tesuque, Santa Clara, Ohkay Owingeh, Taos, Picuris

o Mostly Behavioral Health and Social Services o Butterfly/circle of life, CHR, Title 6 management services

• FSIP inc. serves Zia, Santa Ana, Jemez, Sandia, San Felipe o CHR some Behavioral Health and Social Services, Title 6 management

• UNM medical Group o Specialty Care medical services o Behavioral Health o Laboratory o Radiology

https://www.ihs.gov/Albuquerque/healthcarefacilities/albuquerque/

https://www.ihs.gov/albuquerque/healthcarefacilities/acomacanoncitolaguna/

https://www.ihs.gov/Albuquerque/healthcarefacilities/zuniramah/

https://www.ihs.gov/Albuquerque/healthcarefacilities/taospicuris/

https://www.ihs.gov/Albuquerque/healthcarefacilities/santafe/

http://www.fnch.org/


o Dialysis o Urgent Care

• UNMH Hospital o Inpatient Services o Emergency o Urgent Care

• Lovelace Hospitals o Inpatient Care o Emergency

• Presbyterian Hospitals and Clinics Albuquerque, Espanola Valley. o Primary Care o Urgent Care o Inpatient services o Emergency

• Personal Care Providers: Ambercare, El Mirador Homecare, Consumer Direct, Options Homecare, Silver linings, Southwest Homecare,

• Nursing Home/ Long Term Care Providers: Laguna Rainbow Elder Care, Ladera Center, Santa Fe Care Center, Casa Real, Espanola Valley, Taos Living Center.

Acoma Pueblo:

• Tribal 638 Self-governed o Behavioral Health Services: Acoma Behavioral Health Services, P.O. Box 328,

45 Pinsbarri Drive. Office (505) 552-6661 Fax (505) 552-6426 Autumn Drags Wolf, LMSW Nihal Hassan LMHC Matilda Begay, Mental Health Clinician Lojann Hooee, LADAC, CADAC/ADC Stuart Jones, LSAA/LMHC Brandon Pasquale, CPSD Prevention Generalist

o Health and Wellness Department Referrals and Health Screenings Elder Care Center

• Congregated meals/home delivered • Personal attendant • Respite care • Transportation

Diabetes Support Health and Nutrition Services Medical Transportation Community Wellness Center Community Health Representatives Emergency Fire/Rescue/EMS

Cochiti Pueblo: http://www.pueblodecochiti.org/departments/health-human-services • Tribal

o Community Health Representatives o Dental o Special Diabetes Program o Title 6/elder Center

http://www.pueblodecochiti.org/departments/health-human-services


Congregated Meals/home delivery Health Screenings Support Services Transportation

Isleta Pueblo: • Isleta Health Center: http://isletapueblo.com/health-center.html

o Audiology o Behavioral Health o Dental o Diabetes Prevention Program o EMS o LAB o Optometry o Pharmacy o Physical Therapy o Podiatry o Community Health Representatives

• Isleta Elder Center/ Assisted Living Center: http://isletapueblo.com/assistedlivingfacility.html

o 24/7 onsite care o Individualized Care Plans o Nutritional Services o Medication Monitoring o House keeping o Limited Transportation o Private Rooms o Congregate Meals/home delivered o Adult Day Services o Personal Care

• Fitness Center Jemez Pueblo: 638 FQHC http://www.jemezpueblo.org/Health_And_Human_Services_Department.aspx

• Title 6/Elder Services Center o Congregated Meals/home delivery o Health Screenings o Support Services o Transportation

• Community Health Representatives • Behavioral Health Services • Pharmacy • Dental • Transportation

Laguna Pueblo: http://www.lagunapueblo-nsn.gov/Community_Health_and_Wellness_Department.aspx

• Laguna Health Corporation o Created to develop healthcare services on reservation

• Rainbow Nursing Center o Inpatient long term nursing center

http://isletapueblo.com/health-center.html

http://isletapueblo.com/assistedlivingfacility.html

http://www.jemezpueblo.org/Health_And_Human_Services_Department.aspx

http://www.lagunapueblo-nsn.gov/Community_Health_and_Wellness_Department.aspx

http://www.lagunapueblo-nsn.gov/Community_Health_and_Wellness_Department.aspx


• Community Health and Wellness http://www.lagunapueblo-nsn.gov/uploads/files/CHWD/POL_Community_Resource_Guide.pdf

o Behavioral Health services o Community Health Representatives o Transportation o EMS o Fitness Center o Benefits Services Center o Elder Center

Nambe Pueblo: • Community Health Representatives • Family Health Department/behavioral Health services • Indian Health Services through Santa Fe Service Unit

o https://www.ihs.gov/Albuquerque/healthcarefacilities/santafe/ Ohkay Owingeh:

• Public Health Nurse • Community Health Representatives • Elder Center

o Congregate Meals/Home Delivery Picuris Pueblo

• Public Health Nurse • Indian Health Services through Taos/Picuris Clinic at Taos

Pueblo https://www.ihs.gov/Albuquerque/healthcarefacilities/taospicuris/ • Behavioral Health Through ENIPCinc. http://www.enipc.org/ • Community Health Representatives

Pojoaque Pueblo • Social Services http://pojoaque.org/community/social-services/ • Senior Center

o Congregate Meals/home delivery meals • Community Health Representatives • Indian Health Services out of Santa Fe Service Unit

Sandia Pueblo Health Service Compacted under self-governance • Sandia Health Center

o Medical o Dental o Pharmacy o Physical Therapy o Chiropractic o In-home care o Mental health/substance abuse o Transportation

San Ildefonso Pueblo • Diabetes program • Community Health Services • Title 6/Senior Center

o Transportation o Congregate meals/home delivery

San Felipe Pueblo

http://www.lagunapueblo-nsn.gov/uploads/files/CHWD/POL_Community_Resource_Guide.pdf

http://www.lagunapueblo-nsn.gov/uploads/files/CHWD/POL_Community_Resource_Guide.pdf

https://www.ihs.gov/Albuquerque/healthcarefacilities/santafe/

https://www.ihs.gov/Albuquerque/healthcarefacilities/taospicuris/

http://www.enipc.org/

http://pojoaque.org/community/social-services/


• Diabetes program • Community Health Services • Title 6/Senior Center


• Fitness/wellness Center • Nutrition services • Transportation

Santa Ana Pueblo • Diabetes program • Community Health Services • Title 6/Senior Center


• Wellness Center • Transportation

Santa Clara Pueblo • Diabetes program • Dental Clinic • Community Health Services • Title 6/Senior Center

o Transportation o Congregate meals/home delivery o Adult Day Services

• Public Health Nurse Santo Domingo Pueblo: Kewa Health Corporation FQHC http://www.kp-hc.org/

• Diabetes program • Community Health Services • Title 6/Senior Center


Taos Pueblo • Diabetes program • Social Services • Behavioral Health • Wellness Center • Early childhood • Community Health Services • Title 6/Senior Center


Tesuque Pueblo • Diabetes program • Intergenerational wellness center • Community Health Services • Title 6/Senior Center

o Transportation

http://www.kp-hc.org/


o Congregate meals/home delivery Zia Pueblo

• Diabetes program • Dental Clinic • Community Health Services • Title 6/Senior Center


Zuni Pueblo • Diabetes program • Community Health Services • Title 6/Senior Center

o Transportation o Congregate meals/home delivery o Personal Care attendant o Adult Day Services

March 1, 2018 Daniel Clavio Dear Mr. Clavio, For... · 2018-04-25 · subsidiaries, joint ventures,...

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Transcript of March 1, 2018 Daniel Clavio Dear Mr. Clavio, For... · 2018-04-25 · subsidiaries, joint ventures,...